The purpose of a GYN colposcopic examination is to evaluate the condition of a patient who has cervical, vaginal, vulvar, urethral, or anal lesions be combined either those of whatever additional tests may be necessary to reach a complete diagnosis.

A large variety of abbreviations and nomenclatures have been used to report results. The recording media have included printed forms. Rubber stamps, serial colpo-drawings, and even graphic picture systems.

A uniform way of setting down all the normal and abnormal changes involving the surfaces of the genital area usually makes of easier and more efficient record keeping. Furthermore, this routine facilitates follow-up and improves communication with the referring physician we have devised such an approach, which we call a gynecoscopy record.

 

The examination of Colposcopy

1.   The cervix is soaked with 3% acetic using packing forceps and saturated cotton balls which are left in place for 60-90 seconds. A careful search is made of the vanginal’ fornices’ and parts of the transformation zone and cervix.

2.  The cervix then is stained with quarter strength Lugols iodine and all areas inspected again. After the application areas are identified by their mustard yellow staining reaction.

3.  If no source is found an endocervical curettage (ECC) should always be performed to exclude an endocervical lesion.

4.  The lower vaginal walls should be inspected carefully as the Speculum is withdrawn.

5.  If an explanation for the abnormal smear is not yet apparent the possibility of exfoliation from other sites must be considered e.g. endometrial ovarian fallopian tube or metastasis breast cancer. The possibility of cellular contamination form a urinary lesion should also be considered.

 

After making a colposcopic appraisal it is important to Draw an accurate diagran of the findings to summarize the Appearance of the cervix just examined Biopsy sites should be recorded so that past or future Histology reports can be related to colposcopic diagram.

The radial position of the biopsy is recorded as 1 to 12 Oclock according to a clock face. The cephalic-caudal

Position of the biopsy is recorded as A-Ewhere

A.   Denotes a biopsies proximal to the new SCJ.

B. Denotes a biopsies immediately peripheral to new SCJ

C. Denotes a biopsies from a more distal portion of the transformation zone     

D.    Denotes a biopsies from the cervical portion distal to the original SCJ.

E.  Denotes a biopsies from the vaginal wall.

Diagnostic conization is mandatory for an unexplained cytologyc report predicting moderate dysplasia or worse in a woman with an unsatisfactory

Colposcopic exam. Howeverwhen with faced with an unexplained suspicious smear in younger women and in patients in whom the transformation zone is fully visible the decision for cone biopsy should be individualized. The most common explanation is a papillomavirus infection of the vaginaand such lesions must excluded first.  

 

The overall predictive accuracy of the combined colposcopic index is higher than 95.Furthermoregenerating a colposcopic score is simple.A diagram that defines the colposcopic appearance is drawnpoints are scored for each of the individual criteria and then points are added to give the colposcopic index.

 

 

Warning Signs to Safeguard against Overlooking Invasive Cance:

1.        Yellowish epithelium especially areas that bleed when touched..

2.    Colposopically significant areas (index score  ³ 6 points) with an irregular surface.

3.    Surface ulceration (particularly when bordered by acetowhite epithelium).

4.    Atypical vessels (horizontal surface capillaries disptaying a “tadpole” or “comma”shape;

5.    coarse subepithelial vessles showing an irregular caliber and a long unbranched course).

6.    extremely coarse mosaicism or punctation especially if there are wide irregular intercapillary distances.

7.    Large complex lesions (dull “oyster-white”epithelium occupying 3 or 4 cervical

8.   Quadrants and showing a mixture of high-grade colposcopic patterns).

9.    High-grade corposcopic lesions extending 5 mm into the cervical canal.

10.  CIN 2 or 3 on a tangentially sectioned punch biopsy in which the bas3ment membrane Cannot be defined adequately.

11.  Cytologic evidence of possible squamous carcinoma (CIS cells in large syncytial sheets

12.     prominent nucleoti, bizarre cells or a “dirty background”)

13.   Cytologic evidence of adenocarcinoma in situ.

14.   Recurrent abnormal cytology in a patient previously treated for CIN 3 (e.g. by cryosurgery cone biopsy or hysterectomy).

15.   A Pap smear suggestive of CIN2 or higher in a postmenopausal woman.

 

Table : Scoring system for the Colposcopic Index

 

Colposcopic Sign

Score

Zero Points

One Point

Two Points

Margin  

 

 

 

 

 

 

 

 

 

 

 

Exophytie condylomas;

areas showing a circular or micropapillary contour

semicircular

Lesions with distinct edges.

 

Feathered, scalloped edges.

Lesions with an angular, jagged shape.

“Satellite” areas and acetowhitening distal to the original SCJ.

Lesions with a regular

(Circular or semicircular) shape, showing smooth, straight edges.

 

 

 

 

 

 

 

 

Rolledpeeling edges

 

 

 

Any intermal demarcation between areas of differing colposcopic appearance.

 

 

 

 

 

Color

 

 

 

 

Shinysnow-white color.

 

Areas of faint

(semitransparent)

whitening.

Intermediate shade

(Shinybut gray- white)

 

 

 

Dull reflectance with

oyster-with coler.

 

 

 

Vessels

 

Fine-caliber vessale, poorly formed patterns.

No surface vessals.

 

Definitecoarse

puncation or mosaic.

Iodune

Any lesion staining

Mahogany brown Mustard yellow staining by a minor

lesion(by frist 3 criteria)

Partial iodine

Staining(mottled

pattern)

Mustard yellow staining

of a singnifrcant lesion

(an significant area scoring 3

or more points by the frist three criteria

1. Scores of 0 to 2 are predictive of menor lesions (subclinical HPV infection and CIN 1 ).

2. Scores of 3 to 5 usually indicate a middle grade lesion (CIN 2).

3. Sores of 6 to 8 generally denote an aneuploin epithelium (CIN 3).

 

 


 

An European proposal for a colposcopic calssification

Colposcopic Conclusions

  Colposcopic Terms

Normal findings

a.        Original squamous epithelium

b.       Columnar epithelium(ectopy)

c.        Normal transformation

Abnormal findings

Non suspicion zone

 Unusual transformation    grade 0

Doubtful zones

a. Unusual transformation   grade 1

b. Fine mosaic

c. Fine punctation

d. Fine leukoplakia

e. Erosion

Suspicious zones

a.     Unusual transformation  gradeII

b.     Coarse mosaic

c.     Coarse punctation

d.     Thick leukoplakia

e.     Lrregular vascularisation

f.      Ulcer

 Frank invasive cancer

 Condylomatous aspects

 Miscellaneous

 Inconclusive findings

 

 

Proposed new colposcopic Terminologies

A.      Normal Colposcopic Findings

Original squamous eqithelium

Columnar eqithelium

Transformation zone

B.       Abnormal Colposcopic Findings

1.          Within the transformation zone

  Acetowhite eqithelium

  Punctation

  Mosaic

  Leukoplakia

  Condyloma Accuminata

  Subclinical Papillomavirus Infection

  Atypical vessels

2.          Outside the transformation zone (e.g.ectocervix.vagina.vulva and penis)

Acetowhite epithelium

Punctation

Mosaic

Leukoplakia

Condyloma Accuminata

Subclinical Papillomavirus Infection

Atypical vessels

C.       Colposcopically suspect frank invasive carainoma

D.      Unsatisfactory colposcopic findings

E.       Miscellaneous findings